A 45-year-old man who had left hip-joint pain after falling down to the left side. The patient was capable of performing everyday activities and could walk with an artificial limb after receiving left above-the-knee amputation under the diagnosis of osteosarcoma 20 years ago.

A displaced fracture line was identified in the femoral intertrochanteric region on a simple radiological test (Fig. 1,2) and the same result was confirmed on computed tomography (Fig. 3). In the operation room, the patient was placed in supine position on a general table and the right leg was placed on leg-rest and a half-sheet was placed underneath the 20 cm-amputated left leg (Fig. 4). Closed reduction was performed by conducting skeletal traction and rotation by placing a Steinmann pin (3.6 mm) in the distal part of the fractured part after inserting a guide pin in the inner part of the greater trochanter of the femur (Fig. 5), and intra-medullary device (Gamma3; Stryker, Kalamazoo, MI, USA) (12 mm×170 mm, caput-collum-diaphyseal angle 125°) was inserted starting from the greater trochanter of the femur, and a lag screw and distal locking screw were inserted (Fig. 6). Follow-up was observed 1, 4, and 16 months after surgery, and bone union was observed on plain radiograph at 4 months (Fig. 7). At the 16th month after the surgery, the patient showed 84 scores on the modified Harris hip score test and activities of daily living was restored. Informed consent was obtained for experimentation with human subjects.

Fig. 1
Anteroposterior hip radiograph demonstrating a displaced intertrochanteric fracture.

• Download Figure

Fig. 2
Left hip axial radiograph demonstrating displaced intertrochanteric fracture.

• Download Figure

Fig. 3
Coronal computed tomography image confirming the presence of an intertrochanteric fracture.

• Download Figure

Fig. 4
Preoperative positioning of the patient on a fracture table.

• Download Figure

Fig. 5
(A, B) Fluoroscopic axial image after closed reduction using Steinmann pin by joystick maneuver.

• Download Figure

Fig. 6
(A, B) Fluoroscopic anteroposterior image after insertion of a cephalomedullary device.

• Download Figure

Fig. 7
POP 4 month f/u x-ray.

• Download Figure

The aim of treating femoral intertrochanteric fracture is to enable the patient to walk and acquire stable fixation through an early surgery. In case of below-the-knee or above-the-knee amputation accompanied by intertrochanteric fracture in the same limbs, placing the limb in the fixed boots on a fracture table is difficult because there is no limb to fix on it.5,6) This problem is dominant in displaced fracture where reduction should be conducted.

Several operative positioning techniques have been introduced for patients who have undergone below-the-knee or above-the-knee amputation accompanied by a femoral intertrochanteric fracture. The first technique is to fix the amputated part to traction boots that are upside down to fit to the part.7) This is advantageous for manipulating and maintaining fracture reduction and possibly damages the skin, and is beneficial for evaluating the degree of rotation of the patella. However, the amputated part should be at least 12 cm long; it has its limitation of transferring appropriate force for reduction. The second method is skin traction using tools, including elastic bandage. Although it has less limits regarding skin damage, infection and length of the amputated part, it has a disadvantage of manipulating and maintaining fracture reduction.8) The third technique is manual traction. Although manual traction possibly damages the skin and has less limits on the length of the amputated part, it is difficult to apply sufficient traction and to control rotation; furthermore, it is hard to maintain reduction during surgery.

During the fixation of intertrochanteric fracture of this patient, skeletal traction using Steinmann pins was conducted to reduce fracture and maintain reduction, which has an advantage of not being affected by the length of the amputated part.9,10) However, using this method, there is a chance of losing reduction because of Steinmann pin removal during fixation; furthermore, it may be difficult to stably control the leg rotation. Conducting skeletal traction using Steinmann pins, there may be soft tissue damage and infection of the amputated part. Furthermore, Steinmann pins may be pulled out when inserting them into the osteoporotic bone.

In this study, a Steinmann pin was inserted through minimal stab incision rather than simply using a pin. It prevents chronic skin scar because of soft tissue damage such that it prevents the discomfort of a patient when wearing artificial limb at a later date. Furthermore, pin site infection may be thoroughly prevented because a Steinmann pin is inserted apart from the joint and is inserted only during fracture reduction and maintenance.

Compared to other methods reported in the literature, performing skeletal traction for fracture reduction and maintenance in femoral intertrochanteric fracture using Steinmann pins had no limitation in the length of the amputated part; it is considered to thoroughly prevent soft tissue damage and infection on the insertion site. Therefore, skeletal traction using Steinmann pins is considered to be an effective and safe method for performing femoral intertrochanteric fracture reduction and maintenance in patients with both below-the-knee and above-the-knee amputation, similar to the patient in this study.